Interpreting the Initial Evaluation for Physical Therapy

These flashcards provide key terminology and definitions relevant to interpreting initial evaluations in physical therapy, offering a useful study tool for students preparing for their exams.

Initial Evaluative Note

Document that details the patient's status, including history, problems, assessment, and treatment plan.

SOAP

An acronym for Subjective, Objective, Assessment, and Plan; a method for organizing patient information.

Subjective (S)

The section of the SOAP note that contains the patient's self-reported symptoms and concerns.

Objective (O)

The section of the SOAP note that provides measurable and observable data collected during the evaluation.

Assessment (A)

The part of the SOAP note where the therapist interprets the subjective and objective data to form a clinical judgment.

Plan (P)

The section of the SOAP note that outlines the proposed interventions and treatment strategies.

Progressive MS

A type of multiple sclerosis characterized by a gradual worsening of symptoms over time.

Functional Mobility Training

Therapeutic activities aimed at improving a patient's ability to move safely and effectively.

Short Term Goals (STG)

Specific, measurable objectives aimed to be achieved within a short time frame, usually in therapy.

Long Term Goals (LTG)

General expectations for patient progress that are intended to be met over a longer duration.

Ataxia

A lack of voluntary coordination of muscle movements, often resulting in unsteady movements.

Co-morbidities

Other medical conditions that a patient may have in addition to the primary condition being treated.

Diagnosis

A clinical judgment made based on the evaluation of patient data and history.

Prognosis

The anticipated outcome or course of a disease, which includes expected progress and potential for recovery.

Patient's Goals

The specific objectives expressed by the patient regarding their recovery and rehabilitation process.

When initiating care, what is a key question for the PTA concerning the treatment plan?

Does the current treatment plan align with the patient's diagnosis, prognosis, and stated Short Term and Long Term Goals?

Before implementing interventions for a patient with conditions like Progressive MS or Ataxia, what safety aspect should the PTA consider?

Are the planned interventions safe and appropriate for the patient's current functional status, co-morbidities, and specific challenges like ataxia?

During patient sessions, what question helps a PTA evaluate effectiveness and guide documentation?

Is the patient making progress towards their Short Term and Long Term Goals, and how should this be captured using the SOAP method (S, O, A, P)?